Prevention and Detection of Fraud Waste and Abuse

This is a Medicare-related page; some of the links will take you to non-Medicare information or to a different website. 
 
VNSNY CHOICE is committed to establishing a culture that promotes prevention, detection and resolution of Fraud Waste and Abuse (“FWA”).  It is the policy of VNSNY CHOICE that all employees, agents, contractors, officers, directors, and VNSNY CHOICE first tier, downstream, and related entities (“FDRs”) must report potential instances of non-compliance and fraudulent, wasteful, abusive and criminal activity.  

What is Fraud Waste and Abuse?

Fraud is an intentional misrepresentation of a known fact  made for the purpose of obtaining a benefit or financial gain. 
 
Waste includes any practice that results in an unnecessary use or consumption of financial or medical resources.  Waste does not necessarily involve personal gain, but often signifies poor management decisions, practices or controls. 
 
Abuse is a practice that is inconsistent with accepted business, financial or medical practices or standards, that results in unnecessary cost or in reimbursement.  
 
Together, Fraud, Waste and Abuse are often referred to as FWA.
 
Examples of FWA include:
 
  • By providers:
 
  • Billing for services not provided;
  • Deliberately filing incorrect diagnosis or procedure codes to maximize payment for claims;
  • Quality of care issues;
  • Failure to maintain adequate medical records;
  • Cover-ups in coordination of benefits;
  • Misrepresenting services or dates of service;
  • Billing non-covered services as covered services;
  • An eligible provider billing for services provided by a non-eligible provider or individual;
  • Providing and billing for unnecessary services; or
  • Accepting or offering kickbacks and bribery.
 
  • By members:
 
  • Loaning a VNSNY CHOICE identification card for use by another person;
  • Altering the amount or date of service on a claim form or prescription receipt;
  • Fabricating claims; or
  • “Doctor shopping” (seeing several providers to obtain frequent drug prescriptions) or excessive trips to the emergency room for narcotics.
 
  • By non-members:
 
  • Using a stolen VNSNY CHOICE card to obtain medical services or prescriptions; or
  • Engaging in impermissible sales and marketing practices to steer potential members to or from VNSNY CHOICE plans.
 
  • By VNSNY CHOICE employees:
 
  • Creating false claims or charges;
  • Delaying assignment of a provider to reduce costs;
  • Failing to provide covered services to reduce costs;
  • Engaging in impermissible sales and marketing practices, such as using unapproved promotional materials, falsifying eligibility information, enrolling individuals without their knowledge or offering inducements to members and providers to join; or
  • Changing member or provider addresses to intercept payments
 

How to Report FWA or Compliance Concerns

Anonymous Hotline and Online Reporting Tool 
 
VNSNY CHOICE Hotline: (888) 634-1558
VNSNY Online Reporting Tool: www.vnsny.ethicspoint.com 
Through our Hotline and Online Reporting Tool, individuals can report FWA, compliance concerns or seek guidance about compliance questions:
  • 24 hours, 7 days a week
  • Anonymously, if you choose
  • Without worry of retaliation or intimidation
Any individual may make a report.  
When making a report, please provide as much detail as possible, such as names, dates, and a description of the issue. Unless you prefer to remain anonymous, please include your name and telephone number so that we may contact you if we have any questions during our investigation.
 

VNSNY CHOICE Special Investigations Unit 

VNSNY CHOICE has established a Special Investigations Unit (“SIU”) to investigate reports of FWA.  The SIU includes Special Investigators and data analysts who investigate FWA reports and work with other professionals in the health care industry to identify FWA schemes. 
 

For more information on the VNSNY CHOICE SIU, and tools and processes in place to prevent and detect FWA, please see the VNSNY CHOICE Fraud Detection Manual.

From the VNSNY CHOICE SIU:
 
Be on the lookout for the following common FWA schemes:
 
Upcoding
 
Upcoding is a common scheme in which a service provider will bill Medicare, Medicaid and/or a health plan for services at a greater amount than those that were actually provided. Health care providers engaging in upcoding may submit claims using codes inappropriate for services provided that allow them to be paid a higher rate. 
 
For example:
 
A member visits her primary care physician and explains symptoms such as a runny nose, coughing and a low-grade fever. The physician completes a brief examination, does not order any tests and prescribes an antibiotic for a simple infection. The member spends a total of 10-15 minutes with the physician. Shortly afterward, the member’s health plan receives a claim from the physician with a code or codes that indicate the physician spent 45 minutes with the member, completed several tests, provided multiple prescriptions and diagnosed the member with several conditions. 
 
 
Billing for Services Not Rendered
 
Billing for Services Not Rendered occurs when a health care provider submits a claim to a health care plan in an attempt to get paid for services not provided to the member.  
 
For example:  
 
A Durable Medical Equipment supplier did not provide a member a wheelchair ordered  but submits a claim to the health care plan for the wheelchair.
 
Kickbacks
 
Member Kickbacks occur when any provider, plan member, individual or entity offers any form of compensation to a member in exchange for a member’s information that may allow the party offering the kickback access to health plan payments they otherwise would not have been able to obtain.
 
For example:
 
A provider may offer a health plan member some form of compensation in exchange for permission to use her health plan i.d. number to bill for services they never rendered. 
 
A pharmacy offers a member any kind of compensation in exchange for prescriptions written by the member’s physician. In this scheme, the pharmacy pays the member cash for the prescription, keeps the entire prescription without filling it or only gives him a portion of the quantity prescribed, and bills the health plan for the entire prescription
 
Keep in mind, compensation can be considered anything of value such as money, food, MTA cards, appliances, electronics, cigarettes, etc.
 
 
 

For news release updates from the Office of Inspector General, please visit: http://oig.hhs.gov/newsroom/news-releases/index.asp.

 
Useful Links:
 
NYOMIG: 
 
Health Integrity (NBI MEDIC):

The Centers for Medicare and Medicaid Services (CMS):
www.cms.gov

The Office of Inspector General